Summary On the afternoon of 27 June 2005, the ro-ro passenger ferry Confederation with 114 passengers on board departed Caribou, Nova Scotia, for Wood Islands, Prince Edward Island. The voyage was uneventful until the vessel was making preparations to dock at Wood Islands, when a crew member was discovered trapped in a watertight door. The crew member was quickly freed from the door and subsequently transported to hospital for treatment. Ce rapport est galement disponible en franais. Other Factual Information Particulars of the Vessel Description of the Vessel The Confederation was built in 1993 as a double-ended, roll-on roll-off (ro-ro) ferry to transport passengers and vehicular traffic between Nova Scotia and Prince Edward Island (PEI). The vessel has three vehicle cargo areas on decks A, B and C, with passenger facilities on decks D and E. The vessel has the capacity to carry 600 passengers and 215 private motor vehicles. History of the Voyage At approximately 1620 Atlantic daylight time2 on 27 June 2005, the ro-ro passenger ferry Confederation departed Caribou, Nova Scotia, on its final crossing of the day for Wood Islands, P.E.I. The winds were reported to be from the east at 10 knots with rippled seas. Two members of the engine room crew were carrying out maintenance to a piece of equipment in the engine room. Shortly before the vessel was due to arrive at the ferry terminal, one of the crew members left the engine room to retrieve a part to complete the job. At approximately 1727, the crew member was noticed caught in a horizontal sliding watertight door by his co-worker. The co-worker immediately opened the door, freeing the unconscious crew member. He carefully lowered him to the deck and made him comfortable. Shortly afterwards, the crew member regained consciousness. The vessel continued on to the Wood Islands ferry terminal, arriving five minutes later, where the crew member was treated and transported to hospital by ambulance. There was no observer to the occurrence and the exact circumstances leading up to the occurrence could not be determined. Occasionally, crew members would open the door only as far as was required to allow passage, and they did not always hold either or both operating lever(s) after opening the door. Watertight Doors The Confederation is equipped with three electro-hydraulic watertight doors. Two of the doors are vertical sliding and isolate the two propulsion gear rooms from their respective shaft tunnels, while a third horizontal sliding door isolates the generator room from the engine room. All three doors are capable of being closed from a central location on the bridge and can also be operated locally. Whenever the vessel is in transit, all three watertight doors are controlled and closed automatically from a central location on the bridge. The doors may still be operated locally, but the door will only stay open for as long as the local operating lever is held in the open position. When the lever is released, the door will close. The doors are typically operated in the manual mode when the vessel is secured alongside. In this mode, the doors are opened and closed locally by actuating the operating lever; but when the lever is released, the door movement stops and it remains in that position, at the point the lever was released. It is the practised policy of Northumberland Ferries Limited that the watertight doors be closed from the central location on the bridge whenever the vessel is at sea. This policy is addressed in the vessel's training manual as well as on signage posted at each of the three watertight doors. Additionally, warning signs are posted at each watertight door, instructing Open door fully before entering. Photo 1. Sliding watertight door Regulations Watertight Doors Regulations pertaining to the construction, installation and operation of watertight doors are contained within the Hull Construction Regulations of the Canada Shipping Act. A section that applies to the installation of watertight doors reads in part: handles for controlling the power system shall be provided at both sides of the bulkhead in which the door is situated and shall be so arranged that any person passing through the doorway will be able to hold both handles in the open position simultaneously 3 Post-occurrence trials on the Confederation showed that for all three sliding watertight door installations, it was very difficult to hold both operating levers at the same time. In the case of the horizontal sliding watertight door, the axis of rotation for the operating lever was approximately 51cm from the edge of the door, and it had a 13cm throw. This required the operator of the door to have a reach of approximately 64cm (see photo 3). Photo 3. Reach required to open watertight door holding both levers Photo 4. Opposite side of watertight door In the case of the two vertical sliding watertight doors, the axis of rotation for the operating levers was 37cm and was, therefore, closer to the edge of the door. However, access to the operating levers on one side of both doors was restricted by an angle frame (see photo 6). Additionally, the lever operation of the two doors was not consistent. In one case, the door was opened by pushing the lever, while in the second case the lever was pulled. Photo 5. Aft vertical sliding watertight door; forward door similar Photo 6. Operating lever access hindered by angle frame Watertight Door Operational Requirements/Guidance The service instructions for the watertight door involved in the occurrence indicated that the door must close from fully opened to fully closed in a minimum of 20 seconds and a maximum of 40 seconds. The manufacturer's specification is similar to the Safety of Life at Sea (SOLAS)4 regulations. The SOLAS regulations do not, however, apply to Canadian non-convention passenger vessels such as the Confederation. There are no Canadian regulations that govern the minimum and maximum closing times for sliding watertight doors, and guidance provided by the manufacturer and SOLAS was not used to determine the safe operational parameters of the watertight door. Post-Occurrence Watertight Door Trials The afternoon following the occurrence, watertight door opening and closing time trials were conducted by the Transportation Safety Board and Transport Canada (TC). The following operating times were observed5. Vessel Certification The Confederation is subject to regular inspection by TC as a non-convention6 passenger ship, and it was last issued a Safety Inspection Certificate on 06 June 2005. The vessel also maintains a Lloyds Register Class 100A1, LMCUMS. Personnel Certification The master and officers of the Confederation held certificates valid for the class of vessel and the type of voyage being undertaken. Furthermore, all of the officers and crew had Marine Emergency Duties training, which is consistent with TC's requirements, according to the position they held on board the ship. Personnel History The injured crew member had 30 years of service at sea and 10 years on board the Confederation. He had been certificated as a marine engineer since 1979. Injuries to Persons The crew member trapped in the watertight door suffered major crush-related injuries and was hospitalized.